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Where in the world do patients walk on ventilators and ECMO? Providers from 22 countries share with us their experiences with helping patients walk home from the ICU.

 

Episode Transcription

Kali Dayton 0:28
Okay, let’s talk about walking patients on ventilators. Though one of my favorite topics, I recognize that it is a big and lofty goal that the vast majority in our field, scoff at in disbelief. I hear a lot of resistance and skepticism from critical care providers that I talk to in the United States more developed countries. We pridefully assume that we provide “optimal care” and have the best outcomes. But, do we?

On Twitter, I noticed a lot of discussions about humanizing the ICU coming from providers outside of my own country. It made me ask, “Where in the world are patients walking on ventilators?” Those that do it were passionate and excited to share with us their experiences from all over the world.

Chicago, USA 1:20
My name is Margot Miller and I work as an acute care physical therapist in Chicago and our hospital we have a respiratory therapist when walking our ventilated patients to help manage the portable then recently I ran into a scheduling snafu with a respiratory therapist. But that didn’t stop me and my patient from getting her out of bed. We did some back stepping at the bedside instead. Two weeks later, when she was discharged from the hospital. She shared how much the opportunity to back step with me meant to her. She and her husband loved to dance together. And it was a way of making a very abnormal hospitalization. A little more normal.

San Paulo, Brazil 1:52
Hello, my name is Ivens. I’m a physical therapist specialized in critical care and I work in the city of San Paulo in Brazil. I have been walking patients on ventilators for over 10 years. The first time I walk with a patient on ventilator was in 2009 after reading the article from day on in, in Germany in 2008. The article from Peter Morris in critical care medicine 2008, and an article from William shaker in The Lancet in 2009. We decided to try in our ICU. And the experience was wonderful both for the team and for the patient, who after a few months on a visit to the hospital, told us how important it was to be able to get out of bed and see that he was still able to perform some activities.

Portalegre, Brazil 2:40
Thank you very much for the invitation. We love in your work and we also love early mobilization. Well, we are from Brazil, from the state of Portalegre and the village, the SU. We have been working with early mobilization since the year 2010. In the hospital where you operate use protocols to break sedation and this facilitates the rehabilitation process. You actively partcipate in the progressive gain of functionality. Prioritizng walking in the mechanical ventilation and the functional gain is surprising. We simply love what you do. Thank you very much for this space. 1000 the apologies for our pronunciation in the English language. Keeping doing this excellent job. An important message is to mobilize your patients and use less sedation. I always like to thank you you very much for the space in the where we spread early mobilization as it benefits our to share our knowlege.

Argentina 4:06
Hi, I’m Julie from Argentina. I have a physiotherapist and we work patients with mechanical ventilation and most of these patients has tracheostomy but we also stand up beside the bed patients with endotracheal tube. We use beds that- lifting beds – and we do this from two or three years ago from back that season. And now we are going we we got a confidence and we train the other physiotherapist that don’t belong in the ICU to get courage and knowledge to get this practice done.

The patients on the family- I work in our pediatric hospital- and the patients and the family, they get excited and change the humor, when we can do these things. And also, we get a lot of improvement in respiratory strength. So this is also a benefit when we try to get the ventilator off of them. So this practice, it’s a little bit younger. But we do it. And we try to do it more often, every time but the little patients sometimes are a little bit difficult, but we just have to try and then it goes well, we never had any problem. The patients always tolerated very well. And the confidence that we get with the years and the different patients get a get goddess to do better practices. So we’re very happy with this and we try to getting better and better with us. Bye.

Singapore 6:36
Hello, this is Tanya anesthetists intensivist from Singapore. Together, with a multidisciplinary team, we have managed to walk patients in the ICU on ventilators for the last 10 years. It involves good selection of the patient and multidisciplinary collaboration. And what we found is that this effort has actually helped to improve the patient’s physical condition, as well as to improve their morale and overall cognitive recovery. So this has been very helpful for the overall progress in ICU. Thank you.

Switzerland 7:12
Hi. I’m Sabrina Aikman. I’m a physiotherapist in a large ICU of University Hospital in Switzerland. I love walking ventilated patients in our ICU. In my opinion, the best things is the smiles and the waves you get from the staff and you walk by. And at the end, when you congratulate patients on their effort, and you see them smile, and how the smile gives them back their confidence in themselves. We usually walk patients with a walking aid and assistance of a physiotherapy the ICU nurse is thereby responsible for the installations and the ventilator.

And finally, a nurse assistant works behind the patient with a chair so that she or he can take your wrist whenever they need it. We also walk ECMO patients in this manner. And I think my best memory is when we walked in ECMO patient to Sales Machine to get a Coca Cola. I’m convinced that walking in the ICU provides a psychological benefits to our patients, as it probably relieves their feelings of helplessness and gives them back a sense of recovery and the confidence in themselves. Therefore, every ICU and physiotherapist should evaluate patients for walking as early as possible. Thank you.

London, UK 8:41
Hello, my name is Laura Mylot. I’m a physiotherapist based in London in the UK. And I’m lucky enough to work on Intensive Care Unit where we do mobilize patients who are on ventilators, whether that’s by and large kill tubes or tracheostomy is but also our VV ECMO patients. And I know there are a lot of barriers to completing this. But there are so many positives to doing it, I absolutely love being able to walk a patient who’s on a ventilator. And, and so to all the staff and so do the patients, it gives them something different to do you know, we’re so focused on maybe sitting on the edge of the bed or getting out into a chair for a few hours, but actually being able to walk off the unit potentially, to a corridor an open space or even some units, they’ve got the benefit of a garden. And it just gives that patient that break from that 24/7 Intensive Care Unit environment. It gives them a sense of normality and it also helps obviously, you’re you’re completing rehabilitation, but in a different way.

And I think the psychological benefits of it are amazing. Yes, it takes a fair number of staff and you have to have the right equipment, but actually those things are quite easy to get over. You know, you’ve got various members of your multidisciplinary team that can be involved, I would frequently walk a patient, not just with another physio, but maybe an occupational therapist or with the bedside nurse or maybe even a doctor. And so you can think outside the box and how to make this happen with your patients. And, and obviously, we now want to have our patients awake, alert, engaging in their environment, engaging with staff engaging with their visitors, and to try and speed up the process of getting them out of ICU and getting them home. And this should just be part of that package, essentially, what’s the point in being awake and starting rehab and being at the point of being able to walk if, if we can’t facilitate that just because they’re on a ventilator? So I would just say, give it a bad problem, solve it and have a go. And you will really see that the benefits are amazing, both for you and your patients. Thanks.

Spain 10:59
Hi there. My name is Ricardo Rodriguez Gomez, and I’m a respiratory physiotherapist located at the hospital over Gado Galicia, northwest of Spain. In our ICU, we work with patients on ventilators. I will tell you one of my favorite experiences in our unit, which with patients is since the first 24 to 72 hours, five days per week, we were treating a patient with a pancreatitis that needed to be sedated for almost two months, when you woke up, we increased the work the working rates daily on a daily basis until the day that we negotiated without to walk with a ventilator or expression when first moving out of a room was undescribable.

Showing that all the work was for a good reason and with amazing results. I really appreciate this practice, because it is important that patients feel that they are able to do things and move even when they need help to breathe. As you know, current evidence shows that the more you complete the bundle, the less you need to stay in ICU. That’s what we try to do. More bundles, more bundles so patients can get rid of us as soon as possible. And our fight nowadays is to provide our care seven days per week because we know that patients the health system and the society need our practice to reduce costs economic but mainly human costs.

Ontario, Canada 12:31
My name is Chris Farley and I’m a physiotherapist located in Ontario, Canada. In my role working in the intensive care unit. I’ve had many experiences walking with patients who are mechanically ventilated and my favorite experiences have been whenever I’ve seen a vented patients anxiety and hesitation to try to walk transition to relief and excitement after they’ve actually done the walking. And it’s experiences like this that make working in the ICU so rewarding and enjoyable.

Japan 12:55
Hi, my name is Naruto Nakanishi. I’m working as an ICU physician in Japan. Currently I am working on muscle atrophy zero project in this project. We are trying to reduce muscle atrophy in critically ill patients without intervention critically ill patient experience around 15 to 20% of muscle loss in one week. That’s why our gym right to mobilize patient sometimes we mobilize patient with a ventilator sir patients can walk with our assist. So mobilization is really important. In our research, we showed mobilization intervation can prevent muscle atrophy and improve their outcomes. So I’d like to share more details in our research in the next time.

Michigan, USA 13:51
My name is Elisa Berlage and I work at a large hospital in Michigan providing physical therapy. In the intensive care unit. When a patient is on a ventilator but not overly sedated, it is safe and appropriate to provide them with physical therapy up to and including walking on a ventilator. It can be a lot to manage. When you walk a patient on a ventilator. You have the lines, the monitors the ventilator itself, and it can take increased personnel such as the nurse and the respiratory therapist.

But the benefit of early mobility has been shown to reduce delirium to help patients wean off the ventilator sooner to help the patient maintain their functional strength to help them maintain their quality of life upon discharge. And it has been shown to improve their long term functional outcomes. So when I work in our intensive care units, I Love to promote a culture of early mobility among the other staff members to promote and ensure that each patient receives an appropriate level activity every day. As a doctor of physical therapy, I believe that activity is medicine for the body and the brain. Thank you.

Columbus, Ohio, USA 15:22
My name is Lindsay and I’m a physical therapist in Columbus, Ohio. I love working with patients in the ICU. And it’s a particularly rewarding experience when we can get patients up walking while intubated. I love that it allows a patient to feel more normal, more like their usual selves. And it’s such a unifying experience for everyone involved in the unit. Love seeing nursing, respiratory, other providers cheering on their patients, and it really makes you excited about the work you do.

One of my favorite stories is about a patient that I was working with that was failing her breathing trial every day due to anxiety. She was able to walk up and down the hallway during a PT session. And then her sneaky respiratory therapist after the PT session immediately started her on the breathing trial. In a way she tricked her into thinking that some of those changes in settings or some of that shortness of breath was just attributed to her PT session and feeling fatigued after working out. She was able to pass the breathing trial with flying colors and get activated that afternoon. So it’s a cool story about collaboration and the benefits of working with therapy while intubated.

Chile 16:42
Hi, everyone. My name is Karina Rivera. I am physiatrist and I work in Santiago, Chile, the capital of a country in Latin America, with an extensive coastline on one side and the magnificent Cardillera de los Andes on the other side. My work is in two hospitals, one public hospital Lucencia de Asistencia Publica, and one private Clinica Alemania de Santiago. For five years, I have been working in the rehabilitation of critical patients. And I never imagined that this work would lead me to be at the center of the COVID 19 pandemic, the rehabilitation work with critically ill patients and their families is very exciting, and has been a motivator for me.

Making visible the fears, hopelessness and anxiety of those who are sick has been a huge challenge for me, as well as achieving they continue to rehabilitation after discharge. We have work on it before and after this pandemic. The human species differs from animals for several things. Their ability to speak is one of them. Working upright is another advancing in the motor milestones of a critical patients and putting him on his feet. And taking a few steps is a magical moment. Similar to that of a man on the moon. A small step with a lot of assistance the first time, it means a spark in the dark, that motivates them to keep going. I have accompanied many patients on this new path. I have seen them get excited. I my colleagues have also been excited. Physical therapists, respiratory therapists, occupational therapists, speech language pathologists. This is a reflection of the teamwork of the collective our particular it is what will make us overcome this catastrophe. I invite you to continue on this path around the world, our patients, their families, and our selves the service. We need hope. Thank you very much for Listen to me.

Ecuador 18:41
Hello, my name is Carlos Sanchez. I am an intensive care specialist. I’m head of the critical medicine services of Cubetto General Hospital in Ecuador. The first time I worked with a patient connected to the mechanical ventilation was in the year 2011. What were my fellowship in Venezuela. At that time, it was a totally rare practice. But the patient growth that he wanted to walk during the weaning process. It worked! He had been connected to mechanical ventilation for many days, and we have workedtheir rehabilitation for several days. The patient felt happy, his family did not believe it. And I won the admiration of many people at my work.

Over these years. We have learned that work in a patient connected to mechanical ventilation is not something that should be done with all patients. It’s not for everyone. In fact, they are selected cases but in those which withing they we they will really benefit from it. We do it. If a patient is able to handle connected to the mechanical ventilation, it is almost sure he is going to pass the spontaneous ventilation tests and other predictors of safe activation. During this pandemic, we have provided this management to several patients who due to prolonged ventilation issues are close to a tracheostomy.

And in many of of these patients it has it has been a shift to avoid it without negatively affecting their evolution. Not only the physiological well being that is obtained in the patient is rated. But the change in the pulmonary mechanics due to the change of position. Therefore, it is important to train the health care workers as it is that an approach that takes a little time and staff without harm. However, this should not be an excuse for not giving the best possible opportunity to our patients. Because even thought this seems a small step for humanity. But we are sure it is a great great step for the patient, their family and the healthcare team.

Iowa, USA 21:44
Hi, my name is Alex Mark. I’m a physical therapist at the University of Iowa hospital and I was city Iowa. I’m one of our PTS who covers our medical Intensive Care Unit, which is housed the majority of our critically ill COVID patients since the spring. prior to the onset of the COVID pandemic. Our unit already had a well established culture of early mobility, which included walking patients who are mechanically ventilated on venovenous, ECMO or both. Because of our already established protocols of sedation interruption in early exercise, we were fairly successful in mobilizing many of our mechanically ventilated patients in that initial wave of the pandemic. Like in many other states, however, currently, our normal processes are pretty strain with the record number of hospitalizations and patients who need ICU level care, which has made ventilator mobility more difficult to perform routinely lately.

One area we have had good success with in however is mobilizing our patients on ECMO. For many of them, we have been able to awaken them from sedation even within the first few days of their intubation and cannulation for ECMO. Our first COVID patient placed on ECMO was back in May. She was a 27 year old female who rapidly developed ARDS from COVID. But she was also 24 weeks pregnant when she was placed on ECMO. This case was a first for our program in several ways. As we were not only caring for to live simultaneously, but this was in the face of a novel disease process that we were still learning and we’re still learning about now. Her sedation weaning began on day two of her ECMO run however, we did keep her lightly sedated through day four. As our team wanted to ensure adequate lung protective ventilation given the extent of her lung injury.

Our Maternal Fetal Medicine Service was also following the patient very closely and aside from a few specific hemodynamic and peripheral oxygen saturation parameters, their biggest recommendation was that whatever was good for the mother was good for the baby. So by day five, our team was satisfied with her ventilatory mechanics so we move seriously into waking her up. And on that first day of physical therapy, which was actually successful and standing her up at the bedside without any adverse events. over the preceding day, she continued to tolerate out of bed activity Well, we progressed her bedside activity, but her mobility really peaked on day nine, where she was able to walk the length of her hospital room twice while on the ventilator and during her final trial off of ECMO before BND cannulated later that day. And by this point in her course, we were confident that she would do well with walking.

But our challenge as a team was to perform the test safely with as few people as possible as we were still in a respirator shortage at this point. For this first case, we chose experienced personnel who had a lot of experience in mobilizing patients on ECMO and we were able to accomplish the test safely. This patient ended up discharging home in the care of her family. She was ambulatory and doing well off of supplemental oxygen. Three months later, she delivered a healthy baby girl. Both mom and baby are still doing great to this day. Mobilizing patients while on the ventilator or ECMO is an important intervention to pursue early in the course of critical illness while our patients are still strong. Now not all patients will be candidates but for those who can successfully be weaned from heavy sedation and safely mobilized by an experienced Interesting team, it’s not only beneficial and improving the short term outcomes we look for like decreasing the time on the ventilator decreasing their hospital length of stay, but it’s also increasing the likelihood that that patient can discharge to home from the hospital and preserve a good quality of life in the long term.

Leicester, England 25:14
My name Sean, I fought patients on ventilators in Leicester, England. And I think for me, one of the best reasons to try and get a patient moving on a ventilator is it gives you a really good assessment of that patient. So particularly when a patient’s been in bed for such a long time, and you just don’t know how much strength they’re gonna have retained, you don’t know how much function they’re going to have, when they may do eventually get activated. So getting someone out of bed, getting someone moving, even to sitting on the edge of the bed, doing some reaching doing activities, getting out of a chair moving and walking, if they can, it just really helps to give you a nice idea of how that patient is going to respond post-extubation.

Because if you’ve got a patient that has been in bed for such a long time, you know, there are those wonderful patients that do just jump out our beds, and they’re absolutely fine. And they seem like they’ve never been off the feet. And a patient like that, you can take a bit more of a risk extubation because you’re going to have, you’ve got that safety net have been able to mobilize them, you can get them out of bed, they’re compliant, you can get them moving. So if they do struggle with any atelectasis, or any chest infections, post extubation, you’ve got that fullback on whereas if you’ve got a patient that is a lot weaker, perhaps not got sitting balance, then you really want to be sure about activating that patient at the right time, because there are a lot more likely to fail.

And these the patients, you know, these are the patients that you might be thinking, you know, practically should opt for a tracheostomy just to aid them just to aid give them that backup of ventilator after activating them so that we’ve got time to work on their strength, a bit of a bridge to prevent a tracheotomy. So particularly people that are very tube tolerant, they just really helps you to get a patient out of bed and get them moving. And if you’ve got a patient where they’re just practicing for a couple more days to get over their illness, but they’re awake and they’re alert and they want to move, it just stops you that patient nearly a tracheotomy, which is a highly invasive procedure that has long lasting physical scars, long lasting psychological scars.

So it just helps to reduce that need. And one of the best and best ways of doing early ambulation, in my opinion is, is getting your nursing staff on board and getting your consultants on board. Because if you walk up to someone that doesn’t know you and doesn’t know what you’re about to do, and say, I want to get this patient who’s on lots of drugs that have a ventilator and a tube in their throat and you say want to get them out of bed, they’re just not going to believe you. So it’s about education and supporting the nurse and stuff and little things like if you get a patient out of bed with who’s on a ventilator, go back and help get them back in involving nursing staff, involve your teams. Involve your students involved here, band fives get everyone involved, because that’s the only way that the culture is going to develop and grow. Because if everyone sees it and sees the benefits of it. I’ve also worked a lot more a lot of patients on nippy ventilators which is probably a little bit more common. And they’re just great because they’ve got the battery in so you can just get a patient out and about particularly got someone who’s ventilated via tracheostomy and via nippy and you want to get them outside. It’s just one of the best ways of doing it.

Germany 27:50
Hello, my name is Yan, my team and me we are working with ventilated patients in Audenberg, Germany. In the beginning it took a lot of effort to implement that but when you see the progress of the patients the effort is worth it. And when the routine increases it’s just plain fun.

Montreal, Canada 28:53
Hi my name is gets lotion and I’m an ICU PT in an hospital near Montreal on my unit we walk patients on vent with a tracheostomy or another Tachyon to usually we are three people to carry all the equipment so the RT dinners in me I have a very dedicated team make the patient mobility a priority. The duration is still an issue sometimes but it’s a work in progress to be honest since COVID We didn’t walk patients on then because of the IOCL transmission risk. So instead we use a portable bike or they walk on stance also since COVID We prone lots of patients most of the time where a release date but for the first time few weeks ago we prone an intubated patient was awake, unable to follow commands. We were three people to lpm one RT and two physios he slept for two hours in a prone position with the lights addition in was extubated the next day it’s a teamwork for sure, but it’s possible.

Singapore 29:55
Hello This is Tanya I’m Annie statistic intensive is from Singapore. Together with a multidisciplinary team, we have managed to walk patients in the ICU on ventilators for the last 10 years. It involves good selection of the patient and multidisciplinary collaboration. And what we found is that this effort has actually helped to improve the patient’s physical condition, as well as to improve their morale and overall committed recovery. So this has been very helpful for the overall progress in ICU. Thank you.

India 30:32
My name is karate and I’m from India. While working and now ICU set up in a university based hospital. We used to make patients walk on ventilator, and I followed the practice when I went into a private hospital to work, the nurses were responsible for ensuring that the lines were clear, the patient was not connected to any other lines apart from the ventilator. The hospital assistant or the ICU assistant was working with the patient with the ventilator the physiotherapist was responsible for the overall well being of the patients. The patients were walked while the anesthetist or ICU in charge doctor was on duty after walking even if the patient is on ventilator. It showed increased signs of awareness, alertness, and there was just a general being of happiness in with the patient, which I think helped them get better quickly. Once they realized that they could do something last simple as walking, then it has pushed them to get better in other ways. Also, walking definitely helps even if the patient is on a ventilator.

Abu Dhabi 31:40
Hi, my name is Elmer and I’m a physiotherapist here in Abu Dhabi. And we do ambulate patients that are intubated or rather ventilated in the ICU. If the patients are stable, and or not sedated when they can follow commands, they might be weak, but if they can ambulate, we do mobilize them safely, together with other members of the rehab team like occupational therapies, rehab nurses, you know. I used to work with long term care before as well and for patients that have respiratory failures, but them and and are ventilated, we, we would bring them to the cinemas, you know, but they are that is in a long term rehab care settings. So it’s a very good experience is very fulfilling. I think it can boost the morale of the patients and it can facilitate early discharge.

South Africa 32:49
Hello, I’m a physiotherapist practicing in Cape Town, South Africa, our scope of practice falls within the field of cardiopulmonary rehab and critical care. So we often see patients who are intubated and ventilated for our long term patients, mobilization to the CHE is always part of our treatment. And if the patients are not in any inotropic support or or they are hemodynamically stable, then we will attempt marching on the spot at the bedside because of insulators are not mobile and for those patients that we can take off the ventilator or we will walk them whilst bagging them.

Denmark 33:29
Hello, my name is Frank Hanson. I’m a MD and Senior Consultant intensive care. I’m working small hospital in in Denmark, but for more at Dhaka and the University Hospital in Denmark as well, both places we do non sedation and walk patient on ventilators in my experience is that when you have a patient or non sedated you’re able to talk to them, made them more comfortable onto ventilators. Because they can tell you when it’s good, when it’s bad, when things hurt. On top of that, you can be able to give them physical therapy, which is much better when they awake in the walk.

One of my best experience was a few years ago we had a bed case of ARDS who was awake all time and we used up APRV and high PEEP levels. But still we walked outside on a small patio we have an also on on the heliport on some of the hospital. She came off the ventilator in 15 Days and was outside or discharged from the hospital two days after with minimal requirement for physical therapy in the aftermath. Normally we see that the area’s a dated for a long time, and they need a lot of rehab to reach the level they had before. She has almost the same level when it was just that.

Antigua and Barbuda 35:35
Hello, my name is Dr. Neha Shanbhag and I’m an internist in Mount St. John’s Medical Center, Antigua and Barbuda. We walk our patients that are intubated on mechanical ventilation. We have seen many cases who have been intubated from a period of one week to few months, and have we have been successfully been able to make them walk out of our ICUs. We have done this with constant support from our physiotherapy department and our respiratory physicians. Thank you.

Vietnam 36:14
My name is Anne. I’m an ICU doctor in hospital district 11 In Vietnam. Early mobilization is very important in decreased incidence of ICU acquired witness, shortening the length of the ICU and hospital stay. It takes the effort of our team to have patient move on ventilator step as that daily and walking home from the ICU is our happiness.

Kuwait 36:41
My name is Alexei, senior specialist physiotherapist. I’m a critical care physiotherapist from Kuwait. Nowadays, early mobilization become a cornerstone of ICU medicine and most of ICUs. Here in Kuwait we used to mobilize our patients early and making them to work with the ventilators. Patients with ventilator have to be mobilized early, just get them out of their sedation as soon as possible. I let them more than walk.

And when we’ll do that, we can reduce ventilator associated events, delirium, not only that, if you if your patient develops and muscle weakness, that muscle needs to work harder. So, the body will require more oxygen and produce more carbon dioxide. So we can prevent that by early mobilization and walking. For safe, walking with ventilator, ICU mobilization protocol should be used. We need to do a proper screening, we should weigh benefits versus risks and try to minimize the risk as as much as possible in order to work. Then, a suitable treatment plan should be designed including duration intensity, and we have to know when to stop and when we can modify our treatment. And the most important factor is to work with the multidisciplinary team.

Kali Dayton 38:25
So now we have her testimonials from Ecuador, Singapore, Japan, Germany, Spain, Switzerland, Australia, Denmark, South Africa, Vietnam, Kuwait, Malta, India, Chile, Argentina, Barbuda, Philippines, Abu Dhabi, and many parts of Canada, the USA, Brazil, and England. Providers have confirmed to me the same process in Turkey, Austria, Wales and Ireland. If we are not allowing our patients to wake up and get up, it is usually not because it is not possible. We are failing to provide current and best evidence based practice around the world. Critical Care will continue to progress and evolve across borders, language and culture. The heart of these changes is the same. To further humanize the ICU, and truly save lives as a whole.

Transcribed by https://otter.ai

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